health care

Richard Thaler says behavioral economics and other lessons from Nudge can help bring clarity to the new health care law. He proposes “seamless enrollment,” and “forfeiture, not fines,” and a Ronald Reagan-like nudge. Full column is here.

The fake bus stop outside a nursing home is a well-known example of how health care facilities use choice architecture to keep Alzheimer’s patients from wandering off the property. Another example popped up in the NYT recently, this time about a home in Phoenix, Arizona, that uses carpeting to keep dementia patients from leaving their floor.

And Beatitudes installed a rectangle of black carpet in front of the dementia unit’s fourth-floor elevators because residents appear to interpret it as a cliff or hole, no longer darting into elevators and wandering away.

“They’ll walk right along the edge but don’t want to step in the black,” said Ms. Alonzo, who finds it less unsettling than methods some facilities use, bracelets that trigger alarms when residents exit. “People with dementia have visual-spatial problems. We’ve actually had some people so wary of it that when we have to get them on the elevator to take them somewhere, we put down a white towel or something to cover it up.”

When elevator doors open, Beatitudes staff members stand casually in front, distracting residents with “over-the-top” hellos, she said: “We look like Cheshire cats,” but “who’s going to want to get on the elevator when here’s this lovely smiling person greeting you? It gets through to the emotional brain.”

The feds gave states extra Medicaid money based on how many public health insurance eligible children they could sign-up. Alabama was the big winner thanks to some pre-filled forms. The NYT reports:

Alabama will receive a $55 million bonus, more than twice as much as any other state, for having 133,000 more children on its Medicaid rolls than projected by a formulated base line, according to the Department of Health and Human Services.

To make enrollment easier, Alabama has eliminated asset tests for children, ended requirements for an in-person interview and allowed children to remain eligible for a year without renewal. It also sends out renewal forms with blanks filled in when data is known, and allows applicants to verify their forms with an electronic signature. The state has adopted “express lane eligibility” so that Medicaid application processors can use income findings from other safety net programs to validate eligibility.

1) The Washington Post asked a series of economists what the appropriate tax rates for the richest Americans should be. Time magazine then asked three leading behavioral economists (Richard Thaler, David Laibson, and Dan Ariely) to read those responses and weigh in.

2) People spend more when it’s sunny. Are retailers going to start experimenting with artificial sun lamps? Hat tip: Five Minute Economist.

3) The Department of Health and Human Services releases a computer widget to help you find affordable health insurance.

The Atlantic’s Josh Green says the new health care bill includes a favorite transparency nudge first used with the 1985 Toxic Release Inventory, requiring the measurement of pollution.

There’s a provision in the new health care law that strikes me as intriguingly similar to the (Toxic Release Inventory), and that’s the Physician Payments Sunshine Act, which establishes that doctors must reveal payments from drug companies. We already know, primarily from a series of articles in the New England Journal of Medicine, that this troubling practice has been going on for some time. Someday soon, we’ll know how widespread it is.

In his latest Economic View column, Richard Thaler argues that the debate over what a public option for means for the future of health care in America has gotten way out of hand.

We clearly don’t need any more distractions from the two main issues of health care reform: how to deal with our large uninsured population and how to make the entire system more cost effective. So, for now, let’s ignore the shouted rhetoric about whether “death panels” want to kill off Grandma or whether President Obama wants to turn the country into a socialist state.

But even if we discard these absurdities, and tune out the raucous scenes at town-hall meetings, one big distraction remains: the question of whether a “public option” should be part of the health care solution. To me, the issue is a red herring, and is getting in the way of genuine reform.

Talya Miron-Shatz, a psychology post-doctorate at Princeton with Daniel Kahneman, recently received a crown and a root canal in the same sitting from two different dentists. Since the two procedures were separate from one another, neither dentist seemed to know the local anesthetic that the other was providing to Talya. With poor communication, Talya almost received a double dose of Novocaine (or something similar). There has to be a better way to prevent these kind of errors, she thought.

And here’s my two cents for human engineering. Dental patients wear a bib around their neck. How about if the (dental) office purchased a Sharpie, and had each doctor write down how many injections he/she gave the patient, and their exact location. Better still, how about if this was pre-marked on the bib?

In the field of medicine, there is perhaps no better nudge than Peter Provonost’smedical checklist. Adapted from pre-flight preparations by airline crews, the medical checklist is a six-step set of routine actions for preventing Intensive Care Unit line infections that doctors may otherwise forget to do because of time constraints, stress, or distractions. The success of this checklist in Michigan hospitals has been well documented. After two years the checklist had prevented 43 infections and eight deaths, saving $2m dollars in costs. (The graph below comes from a lecture by former Congressional Budget Office Director Peter Orszag.)

Changemakers, an initiative by the non-profit social entrepreneurship group Ashoka, is preparing to launch a competition to generate medical nudges (more on that in a later post), and the contest organizers have selected the checklist as one of their case study examples. They remind us why the checklist is such a brilliant idea. It’s not the six simple steps. It’s the observing nurses who provide instant feedback ensuring that the medical checklist is followed.

Pronovost’s masterstroke came next: asking ICU nurses to observe doctors’ behaviors after the lists were posted. If they didn’t follow the list, nurses should intervene. Nurses were also to ask doctors daily whether lines ought to be removed, so as not to leave them in longer than necessary.

“When we first said it, the nurses said, ‘Hey, I’m gonna get my head bit off’,” recalls Pronovost. “And docs said, ‘You can’t have nurses second-guessing me in public’. So I pulled all the teams together and said, ‘Is it acceptable that we can harm patients here in this country?’ And everyone said, ‘No’.”…

(Provonost) made the nudge public – involving nurses and reframing the issue as one about harming patients, not authority, Provonost created a cultural shift, empowering everyone in ICU to nudge each other toward right choices to preventing infections.

About

The Nudge blog is the online companion to Richard Thaler and Cass Sunstein’s “Nudge: Improving Decisions About Health, Wealth, and Happiness.” Here you’ll find much more about nudging, choice architecture, libertarian paternalism, and many other terms you won’t read about in standard economics books.

Cass Sunstein is currently the Administrator of the White House Office of Information and Regulatory Affairs and has no affiliation with the Nudge blog.

The Nudge blog is edited by John Balz.

Tell us about a nudge

The possibilities for great nudges are everywhere. For a list of favorites from the book, check out our dozen nudges. We invite readers to send their own nudge suggestions to nudgeblog@gmail.com.

What is Choice Architecture?

Decision makers do not make choices in a vacuum. They make them in an environment where many features, noticed and unnoticed, can influence their decisions. The person who creates that environment is, in our terminology, a choice architect. The goal of Nudge is to show how choice architecture can be used to help nudge people to make better choices (as judged by themselves) without forcing certain outcomes upon anyone, a philosophy we call libertarian paternalism. The tools highlighted are: defaults, expecting error, understanding mappings, giving feedback, structuring complex choices, and creating incentives.

For a user-friendly introduction to choice architecture, check out this paper.